PERSONAL SERVICE FACILITY GUIDELINES

This is a guideline only. Additional Items may be required under the authority of The Public Health Act.

December 2009

Table of Contents

Introduction ……………………………………………………………..… 2

Risks & Informed Consent…………………………………..……..…… 3

Records & Logs ……………………………………………………...…… 3

Construction & Design ……………………………………………..…… 4

Maintenance of Premises & Equipment …………………………….... 5

Cleaning, Disinfection & Sterilization ………………………………… 6

Classification of Items For Disinfection ………………………………. 7

Critical Items Semi-Critical Items Non-Critical Items

General Principles – Equipment, Materials & Instruments ....……. 8

Waste Handling ……………………………………………..……………. 9

Personnel …………………….………………………………………….… 9

Handwashing ……………………………………………………………… 10

Nails & Handcare & Glove Use ………………….………………….….. 11

Temporary & Mobile Personal Service Facilities …………………… 11

After Care For Client ...... ……………………………………………… 12

Appendix 1 Public Health Inspection Contact Numbers Appendix 2 Steps To Clean Instruments Appendix 3 Disinfectant Type And Action Appendix 4 Preparing Household Bleach Solution As A Disinfectant Appendix 5 Classification Of Items For Disinfection Appendix 6 Cleaning and Disinfection of Foot Spas Appendix 7 Major Classes of Chemical Disinfectants and their Relative Advantages and Disadvantages

Introduction

These guidelines apply to premises offering services such as those listed in Table 1. They have been established under the authority of the The Public Health Act S.M. 2006, c.14 to assist operators and personal service workers (PSW) in preventing health hazards from occurring.

Table 1 - Types of Personal Services

Acupuncture Foot Care Skin Care (esthetics) Artificial Nails Hair Services Spas (health & fitness clubs) Body Branding Laser Therapy Steam Bath Body Piercing Manicure/Pedicure Studs Insertion Colonic Irrigation Massage/Therapeutic touch techniques Sugaring Electrolysis Mud Bath Tanning Salons Face and Body Painting Sauna Tattooing Floatation Tank Scarification Waxing Flesh Hook Suspension Shaving

Operators are also responsible for ensuring that they are carrying out their business in accordance with other municipal and provincial legislation that may apply. Some relevant Manitoba legislation includes but is not limited to:

ƒ The Apprenticeship and Trades Qualification Act (A 110) ƒ Trade of Electrologist Regulation MR 105/2006, ƒ Trade of Esthetician Regulation MR 13/2007, ƒ Trade of Hairstylist Regulation 104/2006, ƒ The Manitoba Building Code ƒ The Manitoba Plumbing Code

Electronic copies of Manitoba legislation can be obtained from the following web link: http://web2.gov.mb.ca/laws/

This working document is intended to supplement existing public health requirements and will be used by Public Health Inspectors (PHIs) as a province wide standard in the administration of municipal bylaws and in the investigation of reported health hazards that may arise from the improper operation of a personal service facility.

Risks & Informed Consent

In the establishment of the guidelines Manitoba Health and Healthy Living does not imply that these personal services are beneficial or free of risk. In particular, colonic irrigation, tattooing, body branding, body piercing (including ear piercing) and exposure to ultraviolet radiation in tanning salons carry elevated risk of infection or injury and clients undergoing these procedures should be advised to consider and discuss the

2

risks with their family physician before undertaking such procedures.1 It is important to note that some medications and medical conditions may increase risks involved with particular personal services (e.g. diabetes, allergies, skin infection or damage). The following web site links provide further information on the health risks:

Electrolysis, Tattooing & Piercing: http://www.hc-sc.gc.ca/iyh-vsv/life-vie/tat_e.html http://www.cdc.gov/Features/BodyArt/ http://www.nlm.nih.gov/medlineplus/piercingandtattoos.htm

Tanning: http://www.hc-sc.gc.ca/ewh-semt/pubs/radiation/tan-bronzage/index_e.html http://www.bccdc.org/downloads/pdf/rps/reports/tan_salon_ops.pdf

Consent for minor aged children (<18 years) from a parent/guardian should be obtained and may be required by the local municipality for minors seeking invasive personal service procedures2 and UV radiation exposure from sunlamps (tanning beds).

Some extreme or high risk body art procedures may be considered medical practices (e.g. operations, surgery) under The Medical Act (M90). These procedures may include: branding, scarification, tongue splitting, subdermal implants and ear pointing. It is an offence to practice medicine unless licensed by the College of Physicians and Surgeons of Manitoba. A personal service worker (PSW) carrying out these types of medical procedures shall obtain a licence or exemption from the College of Physicians and Surgeons of Manitoba. Copies of the licence or exception shall be provided to the public health inspector and posted within the facility for public view.

Records & Logs

ƒ Accurate client records shall be maintained in permanent ink for each procedure including: full name of client; home address; telephone number; date of procedure; type of procedure and site of services provided; and name of PSW performing the service. This information is necessary for follow-up in the event of an acquired communicable disease or infection by a client or PSW. ƒ Local bylaws may require date of birth; type of identification with proof of age; and a copy of the signed consent form for invasive procedures and UV radiation exposure from tanning facilities. ƒ Monthly results of spore testing of autoclaves shall be retained in a log (refer to page 6 in this guideline for guidance on cleaning, disinfection and sterilization). ƒ All records shall be kept at the facility and available for inspection for a minimum period of 2 years, or longer if required by the municipal authority.

1 British Columbia Ministry of Health and Ministry Responsible for Seniors, Guidelines for Personal Service Establishments (PSEs), Public & Preventive Health division, August 1995 (revised and reprinted Spring 2000), p. 1 2 City of Brandon, By-Law No. 6685 to regulate body art procedures, April 2002

3

Construction & Design

Prior to design, construction, extensive renovation and operation it may be necessary to submit applications and a floor plan drawn to scale for review and approval to the local municipality and public health inspector. Operators should contact their municipal office and area Public Health Inspector (Appendix 1) for further requirements. ƒ The premises shall be designed specifically for the particular services provided. Personal services facilities are to be entirely separated by solid partitions or walls extending from floor to ceiling, from any room used for human habitation, any food establishment or room where food is prepared, or any other incompatible businesses that may cause potential contamination of work surfaces. ƒ To prevent cross contamination the personal service facility is to be designed so there is sufficient space (e.g. 50 square feet of floor space for each workstation3) and adequate facilities to minimize this risk. Some personal service operations, (i.e. body modification) may require a separate “clean zone” and a “dirty zone”. The procedure is done in the “clean zone” or workstation where only sterilized packages and clean equipment are kept and used. The “dirty zone” is the contaminated area where there is a washing sink and holding basins for cleaning, disinfecting and/or sterilizing instruments. 4 ƒ Where clients may request privacy (e.g. massage service, piercing service) the establishment shall provide an area that is screened from public view. Facilities with multiple workstations shall be separated by dividers or partitions of substantial construction. ƒ Floors, walls, and ceilings in the workstation areas and washrooms shall be constructed of smooth, non-absorbent, durable easily cleanable materials. Carpeting is permitted in reception areas however it is discouraged. ƒ The workstation area of some personal service facilities (e.g. body piercing, tattoo) may be required to have walls, floors and ceilings that are light in colour5 to easily detect soil and contamination. ƒ Tables, countertops and cabinets shall be constructed of smooth, non-absorbent, durable and easy to clean materials. ƒ Furniture used in providing personal services (e.g. barber chairs, treatment beds) shall be made of non-absorbent easily cleanable material. The use of non- absorbent easily cleanable furnishings in reception areas is also encouraged. ƒ The plumbing fixtures shall be conveniently located for personal service staff and customers and be constructed and maintained in accordance with the Manitoba Plumbing Code and the Dwellings and Buildings Regulation. ƒ Where multiple workstations are provided a sufficient number of hand wash sinks may be required (e.g. 1 hand wash sink to serve no more than 3 operators6).

3City of Winnipeg – Body Modification By-law No. 40/2005, s.5(3)(c) 4 Health Canada, Its Your Health Tattooing and Piercing, Fact Sheet, December 15, 2006, p. 2. ( http://www.hc-sc.gc.ca/iyh-vsv/life-vie/tat_e.html ) 5City of Winnipeg – Body Modification By-law No. 40/2005, s.5(1)(j) 6 National Environmental Health Association, Body Art: A Comprehensive Guidebook and Model Code, NEHA, 1999, p.18.

4

ƒ Hand wash sinks shall be supplied with: hot and cold running water and should be dedicated for handwashing only. Installation of “hands free” faucets are encouraged to avoid recontaminating hands. ƒ Ventilation shall be installed in accordance with the Manitoba Building Code. To prevent a health hazard additional and/or separately exhausted ventilation may be required with the use of some chemical products. ƒ The electrical system shall be in accordance with the Manitoba Electrical Code. ƒ The personal service facility shall be adequately lighted for tasks preformed (e.g. 50 - 100 foot candles measured at the 3 foot level)7. ƒ In operations where the patron is enclosed in a small room, ensure that the door opens outward and is unlockable from the outside by staff, to provide easy emergency access.

Maintenance of Premises & Equipment

ƒ The premises, equipment and furnishings shall be maintained clean, in good repair and free of pests. ƒ Instruments and supplies shall be stored in clean, dry and covered containers or areas to protect them from contamination. ƒ At all times during operation there shall be a supply of soap and single use towels from dispensers provided at each hand wash sink. Liquid soap should be stored in dispensers that are disposable or dispensers that are washed and disinfected before refilling. ƒ All sunlamps (including tanning beds) shall comply with the Regulations Amending the Radiation Emitting Devices Regulations (Tanning Equipment) C.R.C., c. 1370 under the Radiation Emitting Devices Act R.S.C. 1985, c.R-1. Tanning salon operators should check with their equipment supplier that their sunlamps and tanning beds comply with the federal law before purchasing any new, used or replacement equipment. To access electronic information relating to the federal legislation visit the following web link: http://canadagazette.gc.ca/archives/p2/2005/2005-02-23/html/sor-dors33-eng.html ƒ Animals shall be prohibited with the exception of service animals trained to assist disabled persons. Animals are prohibited in areas where invasive procedures and cleaning and sanitizing are being done. In personal service establishments that carry out invasive procedures fish are only permitted in reception areas. ƒ The Non-Smokers Health Protection Act SM 1989-90, c. 41 prohibits smoking in enclosed places accessible to the public and indoor workplaces. ƒ Eating shall not be permitted in areas where personal services are provided. ƒ Electrical equipment shall be approved by an accredited certification or inspection body (e.g. CSA, ULC, ETL) and shall bear a label or mark signifying its approval. ƒ Equipment, instruments and supplies used in personal service facilities shall be of durable construction, maintained in good repair, and shall be operated in a safe and careful manner in accordance with the manufacturer’s instructions. Therefore it is important to keep the manufacturer’s instructions on file for reference.

7 City of Winnipeg – Body Modification By-law No. 40/2005 S.5(1)(h)

5

Cleaning, Disinfection & Sterilization

Cleaning, disinfection and sterilization of environmental surfaces, equipment, materials and instruments is essential in the prevention and control of infection within a personal service facility.

“Cleaning” ƒ Removes visible soil from equipment and environmental surfaces. ƒ Must occur as a first step before disinfection or sterilization process or the disinfection or sterilization will be ineffective. ƒ Appendix 2 outlines “Steps To Clean Instruments”

“Disinfection” ƒ Is a process that destroys or kills some, but not all, disease-producing microorganisms on an object or a surface. Health Canada has classified disinfectants as “high level”, “intermediate level” and “low level” (see Appendix 3 Disinfectant Type and Action) ƒ Health Canada's Therapeutic Products Directorate is the federal authority that regulates disinfectants. Disinfectants used in a personal service facility must be registered with Health Canada and bear a drug identification number (DIN). Product searches and further information may be obtained using the following web link (http://www.hc-sc.gc.ca/dhp-mps/index-eng.php ). ƒ Dilute solutions of household bleach (approximately 5% Sodium Hypochlorite) are commonly used as disinfectants. These solutions have been found to be equal or superior to other environmental disinfectants.8 (see Appendix 4 Preparing Household Bleach Solution as a Disinfectant) For a list of Major Classes of Chemical Disinfectants and their Relative Advantages and Disadvantages see Appendix 7. ƒ When using any chemical, operators shall follow the manufacturer’s directions for use and chemicals shall be properly labeled. A material safety data sheet (MSDS) should be obtained, used in staff training and kept on file. ƒ For more detailed information on disinfection, reuse of chemical disinfectants, disinfectants and safety, registration of disinfectants and product labeling see page 13-19 of Health Canada’s Infection Control Guidelines Hand Washing, Cleaning, Disinfection And Sterilization In Health Care (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf)

“Sterilization” ƒ Is a technique that destroys all microorganisms by heat, chemical or gasses. ƒ Certain types of autoclaves are not suitable for use on all items or materials, or in all applications. Where hollow or packaged instruments (e.g. piercing needles, receiving tubes, tattoo tubes) are to be sterilized, written verification must indicate

8 Rutala WA, Weber DJ. 1997. Uses of Inorganic Hypochlorite (Bleach) in Health-Care Facilities, Clinical Microbiology Reviews, p. 597-610.

6

that the autoclave is suitable for such uses. This written verification can be provided by the manufacturer of the autoclave, or by the manufacturer of the instrument.9 10 ƒ Heat sterilization should be used whenever possible and may, in fact, be the required process under some municipal bylaws 11 ƒ When sterilizing “critical items” they shall be packed individually in peel-packs and sterilized. Peel packs are to be opened in front of the customer receiving the personal service. ƒ To monitor each sterilization cycle a time/temperature test strip must be placed in the unit or the peel packs must have a sterilizer indicator. ƒ A monthly spore test must be done by an accredited lab to verify the effectiveness of each heat sterilizer used in the establishment.

Classification of Items for Disinfection (see Appendix 5)

Equipment, instruments and materials used in personal service establishments fall into one of the following three categories and must be cleaned and disinfected or sterilized according to their use.

“Non-Critical Items” ƒ Are those items which come in contact with intact skin but not with mucous membranes. (i.e. head rests, combs, foot baths, surfaces of a tanning bed) ƒ Must be thoroughly cleaned and disinfected between clients ƒ Instruments that accidentally break the skin during use (e.g. scissors) must be thoroughly cleaned and sterilized after being in contact with blood. In some cases, as a minimum, these instruments may be disinfected with a high level disinfectant after being cleaned. (refer to Appendix 3 Disinfectant Type and Action)

“Semi-Critical Items” ƒ Are those items which come in contact with the mucous membranes, such as the eyes, ears, nose, mouth or any other body orifices, or with skin that is not intact, (e.g. instruments used for acne treatment) ƒ Must be purchased as sterile and disposed of after a single use, or treated using high level disinfection after each use.

“Critical Items” ƒ Are those which may puncture the skin or enter sterile tissue such as needles and razors. ƒ Must be purchased as sterile from reputable suppliers or manufacturers and be properly disposed of after a single use or sterilized between each use (e.g. needles, razors used to shave skin which have a high potential to cut the skin)

9 MacDonald, J.A. and Chu, D. 2009. “Suitability of Most Steam Autoclaves to Sterilize Tattooing and Body Piercing Instruments – Implications for Environmental Public Health Inspection”. Environmental Health Review. 53(3):70-73. 10 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, p. 20.. 11 City of Winnipeg, Body Modification By-law No. 40/2005, p. 8.

7

General Principles - Equipment, Materials & Instruments

ƒ Multi-use items that can not be properly cleaned and disinfected or sterilized may be prohibited (i.e. piercing gun with a solid head that does not have a disposable sterile cartridge) ƒ Equipment, instruments and material intended for single service use upon patrons and those that can not be disinfected or sterilized adequately shall be considered disposable and shall not be reused. (i.e. emery boards, orangewood sticks, disposable needles, stencils, gauze, foot basin liners) ƒ Equipment, supplies and instruments that have been disinfected or sterilized shall be stored and handled in a manner to protect them from contamination (e.g. appropriate autoclavable packaging) ƒ Health Canada regulates cosmetics and personal care products (e.g. tattoo inks, skin lotions) regarding composition, safety, labeling and advertising under the Food and Drugs Act R.S., 1985, c. F-27. Further information can be found using the following web link (http://www.hc-sc.gc.ca/cps-spc/person/cosmet/info-ind-prof/index-eng.php ). ƒ Inks, creams, lotions, powders, and other cosmetics shall have ingredient labeling. They shall be kept in clean, closed containers and single-service portions that are left over should not be used for another client. ƒ To prevent contamination of bulk materials dispense them using one of the following: - a clean single service spatula to remove a portion of the substance from its container; - a metal or plastic collapsible tube; or, - individualized single-service portions. ƒ Fluids that come in contact with mucous membranes shall meet semi-critical disinfection requirements (as defined in Appendix 3). Fluids that come into contact with subcutaneous tissue shall be sterile. ƒ Materials used as bandages should be manufactured for medical use (e.g. tattooed skin should be covered with a dry sterile dressing indicated for medical use12.13 ) ƒ Furniture that comes into contact with the client’s intact skin may be covered with clean paper, freshly laundered linen or approved single-use material before each patron uses the equipment (i.e. massage treatment bed). Treatment beds and furniture used for invasive procedures (e.g. tattoo, piercing, electrolysis) must be cleaned and disinfected prior to each use even when lined with fresh paper or linen. ƒ If a protective cape or cover is used around a client’s neck a neck strip or towel shall be used to keep the protective cover from directly contacting the client’s skin. ƒ Linens such as towels, and pillow coverings should be washed in domestic or commercial machines. Dryers should be set at the hottest temperature.

12 Medical Devices Regulations (SOR/98-282) http://laws.justice.gc.ca/en/f-27/sor-98-282/text.html 13 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, p. 32.

8

Waste Handling

ƒ Place paper towels, tissues and other potentially contaminated items into waste receptacles lined with plastic bags. Waste receptacles shall be conveniently located and emptied daily. ƒ Sharps such as needles or razor blades shall be placed in approved puncture- resistant sharps containers with tight fitting lids and marked with the biohazard symbol. Sharps should not be purposely bent, broken, recapped, etc by hand. The container should be stored close to the personal service worker. ƒ Sharps containers must be handled and disposed in accordance with municipal waste disposal requirements. For further information check with your local municipal office and/or Manitoba Conservation.

Personnel

ƒ Ensure that persons engaged in providing services: - Wash hands and practice acceptable personal hygiene; - If known to have a communicable disease or skin lesions on hands, observe appropriate infection control precautions (e.g. mask for service worker or client for respiratory tract infection, glove use if chapped or cracked hands); - Wear clean outer garments; - Use and maintain instruments and equipment in a manner to prevent a health hazard from occurring (e.g. sterile equipment should be assembled with gloved hands); - Demonstrates competency in using equipment and procedures and meets the requirements set by legislation and the field of practice (e.g. PSWs shall assess the condition of a client’s feet and legs before a foot bath soak and if there is any condition that has weakened the skin barrier such as recently shaved legs, insect bites and scratches this may pose a increased risk of infection and the client should be advised not to use the foot bath. 14); and - Are familiar with regulations, guidelines, bylaws and infection control practices specific to the service provided. Persons providing tattooing, piercing, and electrolysis should be following the Health Canada Infection Prevention and Control Practices For Personal Services: Tattooing, Ear/Body Piercing, And Electrolysis. (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s3e.pdf) ƒ All staff that perform invasive procedures should have up-to-date immunizations as recommended for adults in Canada, including diphtheria and tetanus every 10 years. Because of potential exposure to blood, practitioners are advised to receive three doses of hepatitis B vaccine.

14 United States Environmental Protection Agency http://www.epa.gov/pesticides/factsheets/footspa_disinfection.htm)

9

ƒ Penetrating injuries from needles or sharp items should be managed according to the Manitoba Health “Integrated Post-Exposure Protocol - Guidelines for Managing Exposure to Blood /Body Fluids”. November 2003 which can be obtained electronically at the following web link: ( http://www.gov.mb.ca/health/publichealth/cdc/fs/ipep.pdf )

Handwashing

Hand washing is the most effective way of preventing the spread of disease. Use the designated hand wash sink(s) and the following handwashing procedures to protect you and your clients. 1) Remove all jewelry. 2) Rinse hands with warm running water. 3) Apply liquid soap and lather well. Antiseptic soaps are recommended and may be required by some jurisdictions prior to performing invasive procedures (tattoo, piercing). 4) Rub hands vigorously making sure you cover all surfaces of the hands and fingers (at least 20 seconds or longer if visibly soiled). 5) Rinse hands well under warm running water. Leave the water running. 6) Dry hands with a single-use towel. Drying helps reduce number of germs. 7) Turn off the water using the single use towel to avoid re-contamination hands.

Waterless Handwashing – Hand Sanitizer

ƒ Hand washing with waterless/alcohol-based agents is equivalent to soap and water15. However, the use of hand sanitizers does not eliminate the need for adequate handwashing facilities and practices because “if there is heavy microbial soiling, hands must first be washed with soap and water to remove visible soiling).”16 ƒ Alcohol strength shall be 70% to 90% with added emollients (glycerine or cetyl alcohol is less drying) ƒ Must be used on dry hands because moisture from wet hands dilutes the alcohol

How to Handrub17 1. Apply 1 to 2 pumps of product to palms of dry hands. 2. Rub hands together, palm to palm. Rub in between and around fingers. 3. Rub back of each hand with palm of other hand. 4. Rub fingertips of each hand in opposite palm. 5. Rub each thumb clasped in opposite hand. 6. Rub hands until product is dry. Do not use paper towels. 7. Once dry, your hands are safe.

15 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, p. 7. 16 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, p. 7. 17 Ontario Ministry of Health and Long-Term Care, Just Clean Your Hands http://www.justcleanyourhands.ca/pdf/10_14_Handrub_07Feb08.pd, January 2008

10

Nails, Handcare & Glove Use

ƒ Hand lotion may be used to prevent skin damage from frequent handwashing. Lotion should be kept in disposable containers/non-refillable containers to avoid contamination. ƒ Artificial nails or chipped nail polish may increase bacterial load and makes soil under the nails hard to see so the use of nail polish and artificial nails is discouraged.18 This is especially important for those personal services workers carrying out invasive procedures. ƒ Gloves are not a substitute for handwashing. Hands must be washed before putting on new gloves and also after removing gloves. Gloves are used to reduce the risk of disease transmission and should be worn when carrying out invasive procedures such as body piercing and tattooing. Gloves should also be used when a personal service worker has an open sore on their hands to avoid transmitting infection to the client or themselves. When using gloves, it should be remembered that: - Gloves should be used for a specific procedure and removed before leaving the client for any reason, (e.g. to answer the phone, to attend to another client) - Gloves should be disposed of after use; not washed or reused. - Some clients and personal services workers may have latex allergies. If latex is chosen non-latex gloves should be available for clients and staff with a latex sensitivity. The use of low protein and un-powdered latex gloves may reduce risk of developing a latex allergy. ƒ Reusable utility gloves (e.g. neoprene, rubber, butyl) should be worn for cleaning/disinfecting equipment. These may be cleaned and reused while they are in good condition. ƒ For more information on hand hygiene and gloves see pg 1-8 of the following weblink (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf)

Temporary & Mobile Personal Service Facilities

ƒ Some municipal bylaws may restrict the operation of mobile and temporary personal service facilities and/or require a licence or permit prior to operation. ƒ The premises and equipment shall comply with the construction, design and maintenance standards outlined in this guideline. (e.g. cleanable surfaces, lighting, space, handwashing and toilet facilities, sanitary storage of supplies) ƒ If the personal service involves the use of “critical items” and the operator is affiliated with a fixed location copies of spore test logs shall be available at the temporary or mobile location. This may not be necessary if only single use, prepackaged, sterilized equipment from reputable suppliers or manufacturers is on site and used. The personal service worker shall demonstrate and follow infection control practices outlined in this guideline including waste management specific to the event and community requirements.

18 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, Document Dissemination Division at the laboratory Centre for Disease Control, December 1998, p. 5.

11

After Care For Client

ƒ Oral and written instructions for care at home should be provided to the client and may be required under some municipal bylaws.19 ƒ The signs and symptoms of possible complications including infection and allergic reaction should be discussed. (e.g. Do not remove jewelry from an infected piercing, but seek medical advice.)

For further clarification regarding infectious disease transmission and methods for prevention of infectious disease, the operators should call their local Public Health Inspector. (See Appendix 1 Public Health Inspection Contact Numbers)

19 City of Winnipeg, Body Modification By-law No. 40/2005, p. 15.

12

APPENDIX 1

Public Health Inspection Contact Numbers

Manitoba Health & Healthy Living - Public Health Inspection Offices Phone the one nearest you (area code 204):

Brandon 726-7001 Dauphin 622-2126 Killarney 523-5285 Lac du Bonnet 345-1447 Portage la Prairie 239-3187 Selkirk 785-5210 Steinbach 326-2733 The Pas 627-8307 Thompson 677-6472 Morden 822-2850 Winnipeg 945-3181

ƒ City of Winnipeg – Environmental Health Branch (Phone 311)

APPENDIX 2 Steps to Clean Instruments20

Cleaning Process Comments 1 Soak items that cannot be immediately Used instruments should be soaked to cleaned in basin of cool water with or prevent blood and other organic matter without detergent. from drying on the item. Do not soak dirty items in hot water or a disinfectant before cleaning, because it causes the soil and matter to stick to the surface of the object. 2 Put on utility gloves (non-medical gloves). Utility gloves are suitable for cleaning and have a wider bib at the wrist to help prevent water from entering the inside of the glove. They are also reusable and therefore economical. Some items may require a more delicate glove. 3 Take instruments apart and rinse in luke- Hot water makes body proteins stick to warm running water. objects. 4 Prepare cleaning sink by adding warm Ensure that objects are visible by using a water and detergent. low sudsing detergent. 5 Clean instrument surfaces by using Scrub below the water surface to prevent friction (washing and scrubbing motions). splashing into the eyes or on the clothing. Use a small brush to clean any crevices An ultrasonic cleaning device, with a lid, or seams in instruments, e.g. hinges. may be used for cleaning. 6 Drain dirty water. Rinse cleaned Rinsing removes residual detergent and instruments in clean, warm water. soil that may impair the function of the instrument or interfere with the action of disinfectants. 7 Either air dry or dry with a lint free towel. If wet items are not dried a film may be left on the surface (biofilm), which contains microorganisms. 8 Store cleaned instruments in a covered Uncovered, clean instruments may container until disinfected or sterilized, if become contaminated by dust or required. moisture. 9 Remove utility gloves; wash, rinse and Cleaned utility gloves may be used again hang to dry. as long as the rubber is not torn or punctured. 10 Wash hands. Hands should be washed after glove removal to avoid contamination.

20Health Canada Infection Prevention And Control Practices For Personal Services: Tattooing, Ear/Body Piercing, And Electrolysis, July 1999, p. 9 (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s3e.pdf)

APPENDIX 3 Disinfectant Type and Action21

Disinfectant Action Comments LOW LEVEL Effective for non-critical DO NOT use to disinfect The most common are items. instruments. quaternary ammonium Kills some bacteria and Always add to water compounds or Quats. viruses e.g. staphylococcus, according to Some phenols and 3% herpes, HBV, HCV and HIV. manufacturer’s directions. hydrogen peroxide are Does not kill Mycobacterium included in this group. tuberculosis, fungi, or Generally, not irritating to spores. the practitioner. INTERMEDIATE LEVEL Effective for some semi Mostly non-toxic, but some 70% isopropyl alcohol, critical items. iodophors and bleach burn 5.25% household bleach Kills the microorganisms for skin and stain fabrics. and iodophors, e.g. iodine low level disinfectants plus Bleach mixture: 1 part solutions are included in fungi but does not kill bleach and 9 parts water this group. Mycobacterium should be prepared every tuberculosis, or spores. 24 hours. Household bleach is not a good choice for disinfection of metal instruments or equipment as corrosion is a problem. HIGH LEVEL Used for semi critical items Glutaraldehyde is non- Common examples are and for critical items that corrosive but is irritating to 2% glutaraldehyde and cannot withstand heat the skin and vapours are 6% hydrogen peroxide sterilization. toxic. (stronger that the 3% Kills all viruses, bacteria NEVER use glutaraldehyde hydrogen peroxide found (including Mycobacterium as a spray. Good in the drug store). tuberculosis) but does not ventilation is required when kill spores. These products using this product. are able to sterilize objects 6% hydrogen peroxide can with longer soaks according be corrosive to some to times suggested by the metals. e.g. aluminum. manufacturer.

21Health Canada Infection Prevention And Control Practices For Personal Services: Tattooing, Ear/Body Piercing, And Electrolysis, July 1999, p. 13 (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s3e.pdf)

Appendix 4 Preparing Household Bleach Solution as Disinfectant 22 23

Note: The strength of household bleach solutions weaken when diluted with water so to maintain optimum strength it may be necessary to mix new solutions daily or to make a higher concentrated solution to maintain effectiveness. 24

1:100 Household Bleach Solution 0.05% or 500 ppm

• Intermediate level disinfection used for disinfecting non- critical items and surfaces. • 50 ml household bleach + 4950 ml of water (¼ cup bleach + 24 ¾ cups water) • 5 ml household bleach + 495 ml of water (1 tsp bleach + 2 cups water)

1:10 Household Bleach Solution 0.5% or 5000 ppm

• High level disinfectant used to decontaminate semicritical items and surfaces. • 250 ml household bleach + 2250 ml water (1cup bleach + 9 cups water) • 125 ml household bleach + 1125 ml water (1/2 cup bleach + 4 ½ cups water) • 50 ml household bleach + 450 ml water (¼ cup bleach + 2 ½ cups water)

22 Ontario Ministry of Health, Personal Services Settings Protocol Infection Control Program, January 1998 23 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, Document Dissemination Division at the laboratory Centre for Disease Control, December 1998 (http://www.phac- aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf) 24 Rutala WA, Cole C, et al Stability and Bactericidal Activity of Chlorine Solutions, Infection Control and Hospital Epidemiology May 1998 Vol. 19 no. 5 p 323-327

APPENDIX 5 Classification of Items for Disinfection25

Classification Disinfectant Method NONCRITICAL Items that Low level disinfectants are good may come into contact with intact for noncritical items. skin and/or are used for routine housekeeping. Items that are rarely Detergent is adequate. Clean to remove dust or soil from contaminated with blood/body items/equipment and surfaces with a solution fluid, e.g. client chair and table, of detergent and warm water. sponge holder, electrolysis machine arm holding the electrolysis magnifying glass. Items that are often Low level disinfectants, e.g. Clean and follow with low level disinfection for contaminated with blood/body quaternary ammonium reusable items and environmental surfaces fluid, e.g. lamp handles, clip compounds or Quats, or a that may be contaminated. Wet or spray a cord, dirty instrument tray, tattoo combination of a low level paper towel to wipe the clean item/surface motor frame, tattoo chuck or disinfectant-detergent; 3% with the disinfectant prepared and used clamp, pump packs, spray bottle, hydrogen peroxide compounds. according to the manufacturer’s direction, i.e. electrolysis magnifying glass. allow sufficient surface contact time with the disinfectant. SEMICRITICAL items come Intermediate and high level into contact with mucous disinfectants are good for items membrane or non-intact skin or that come into contact with they hold a sterile item. mucous membranes or non-intact skin or that hold a sterile item. Items that cannot be soaked and Intermediate level disinfectants, Clean item is wet wiped with an intermediate hold a sterile item that may have e.g. 70% isopropyl alcohol or 1 level disinfectant and air dried after each been splattered with blood/body part 5.25% household bleach and client. fluids, e.g. pin device that holds 9 parts water. Bleach may be electrolysis needle. corrosive to metals. Items capable of being soaked High level disinfectants, e.g. 2% Clean item is soaked for a number of and hold a sterile item that may gluteraldehyde or 6% hydrogen minutes, as specified by the manufacturer, to have been splattered with peroxide. achieve a high level of disinfection. blood/body fluids, e.g. plastic needle pusher. CRITICAL items enter deep in Sterile items must be used to the skin, e.g. tattoo or ear/body enter the skin. piercing needles, hypodermic needle used during electrolysis, jewelry. Metal items to pierce the skin Pre-sterilized, single use, packaged needles should be purchased sterile or or ear ring studs should be used. Items that packaged and sterilized by a are not pre-packaged as sterile must be steam or dry heat method. sterilized. Sterile electrolysis needles should never be saved and reused on the same client. Chemicals that sterilize are not recommended for critical items as it is difficult to monitor and confirm that sterilization has been achieved and the packaging of items to maintain sterility is not possible.

25 Health Canada Infection Prevention And Control Practices For Personal Services: Tattooing, Ear/Body Piercing, And Electrolysis, July 1999, p. 11-12 (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s3e.pdf)

APPENDIX 6 Cleaning and Disinfection of Foot Spas26

After Each Client: (this can take place any time after the client's feet are out of the footbath, while feet are massaged, toes are painted, or other opportunities)

1. Drain the water from the foot spa basin or bowl and remove any visible debris. 2. Clean the surfaces of the foot spa with soap or detergent, rinse with clean water, and drain. 3. Disinfect the surfaces with a Health Canada registered disinfectant according to the manufacturer's directions on the label. Surfaces must remain wet with the disinfectant for 10 minutes or the time stated on the label. * For whirlpool foot spas, air-jet basins, "pipe-less" foot spas, and other circulating spas: It is best to disinfect by filling the basin with clean water, adding the appropriate amount of liquid disinfectant, and turning the unit on to circulate the disinfectant for the entire contact time. 4. After disinfection, drain and rinse with clean water.

Nightly:

For whirlpool foot spas, air-jet basins, "pipe-less" foot spas, and other circulating spas:

1. Remove the filter screen, inlet jets, and all other removable parts from the basin and clean out any debris trapped behind or in them. 2. Using a brush, scrub these parts with soap or disinfectant (following cleaning directions). 3. Rinse the removed parts with clean water and place them back into the basin apparatus. 4. Fill the basin with clean water and add a Health Canada registered disinfectant following label directions. Turn the unit on and circulate the system with the liquid for 10 minutes, or the label-indicated contact time if different. (The whirlpool mechanism of the tub must be operating for the entire disinfection period so the piping and internal components that contain hidden bacteria are disinfected.) 5. After disinfection, drain, rinse, and air dry.

For simple basins (no circulation):

1. Drain the basin and remove any visible debris. 2. Scrub the bowl with a clean brush and soap or disinfectant (following cleaning directions). Rinse and drain. 3. Disinfect basin surfaces with and EPA-registered hospital disinfectant, following manufacturer's instructions. Surfaces must remain wet with the disinfectant for 10 minutes or the contact time stated on the label. 4. Drain the basin, rinse with clean water, and let air-dry.

26 United States Environmental Protection Agency http://www.epa.gov/opp00001/factsheets/footspa_disinfection_page.pdf

Appendix 7 Major Classes of Chemical Disinfectants and their Relative Advantages and Disadvantages27

MANUFACTURERS’ RECOMMENDATIONS FOR CONCENTRATION AND EXPOSURE TIME MUST BE FOLLOWED.

Disinfectant Uses Advantages Disadvantages

Alcohols Intermediate level disinfectant Fast acting No Volatile Evaporation may diminish Disinfect thermometers, external residue Non concentration. Inactivated by organic surfaces of some equipment (e.g., staining material. May harden rubber or cause stethoscopes). Equipment used for deterioration of glues. Use in the OR is home health care. Used as a skin contraindicated antiseptic

Chlorines Intermediate level disinfectant Low cost Fast Corrosive to metals Inactivated by Disinfect hydrotherapy tanks, acting Readily organic material Irritant to skin and dialysis equipment, available in non mucous membranes Unstable when cardiopulmonary training manikins, hospital settings diluted to usable state (1:9 parts water) environmental surfaces. Effective Use in well-ventilated areas Shelf life disinfectant following blood spills; shortens when diluted aqueous solutions (5,000 parts per million) used to decontaminate area after blood has been removed; sodium dichloroisocyanurate powder sprinkled directly on blood spills for decontamination and subsequent cleanup. Equipment used for home health care.

Ethylene oxide Used as gas for the sterilization of Sterilant for heat or Slow acting and requires several hours of heat sensitive medical devices pressure sensitive aeration to remove residue. One of its equipment carriers (chlorofluorocarbon) is now a restricted chemical.

Formaldehyde Very limited use as chemisterilant Active in presence Carcinogenic Toxic Strong irritant Sometimes used to reprocess of organic materials Pungent odour hemodialyzers Gaseous form used to decontaminate laboratory safety cabinets

Glutaraldehydes 2% formulations — high level Noncorrosive to Extremely irritating to skin and mucous disinfection for heat sensitive metal Active in membranes Shelf life shortens when equipment Most commonly used for presence of organic diluted (effective for 14-30 days endoscopes, respiratory therapy material Compatible depending on formulation) High cost equipment and anesthesia with lensed Monitor concentration in reusable equipment instruments solutions Fixative Sterilization may be accomplished in 6- 10 hours

27 Health Canada, Infection Control Guidelines Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, Document Dissemination Division at the laboratory Centre for Disease Control, December 1998 (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf)

Disinfectant Uses Advantages Disadvantages

3% — low level disinfectant Equipment used for home health care(59) Cleans floors, walls and furnishings 6% — high level disinfectant. Effective for high level disinfection of flexible endoscopes. Strong oxidant Fast acting Can be corrosive to Hydrogen peroxide Foot care equipment. Disinfection of Breaks down into water and aluminum, copper, brass or soft contact lenses. Higher oxygen zinc concentrations used as chemisterilants in specially designed machines for decontamination of heat sensitive medical devices

Iodophors Intermediate level disinfectant for Rapid action Relatively free of Note: Antiseptic iodophors some equipment (hydrotherapy toxicity and irritancy are NOT suitable for use as tanks, thermometers). Low level hard surface disinfectant. disinfectant for hard surfaces and Corrosive to metal unless equipment that does not touch combined with inhibitors. mucous membranes (e.g., IV poles, Disinfectant may burn wheelchairs, beds, call bells) tissue Inactivated by organic materials. May stain fabrics and synthetic materials.

Peracetic acid High level disinfectant or sterilant Innocuous decomposition Can be corrosive Unstable for heat sensitive equipment. Higher (water, oxygen, acetic acid, when diluted. concentrations used as hydrogen peroxide). Rapid chemisterilants in specially action at low temperature designed machines for Active in presence of organic decontamination of heat sensitive materials. medical devices.

Phenolics Low/intermediate level Leaves residual film on Do not use in nurseries. Not disinfectants. Clean floors, walls environmental surfaces. recommended for use on and furnishings. Clean hard Commercially available with food contact surfaces. May surfaces and equipment that does added detergents to provide be absorbed through skin not touch mucous membranes (e.g., one-step cleaning and or by rubber. Some IV poles, wheelchairs, beds, call disinfecting. synthetic flooring may bells. become sticky with repetitive use.

DO NOT use to disinfect Generally non- irritating to Quaternary Low level disinfectant. Clean floors, instruments. hands ammonium walls and furnishings. Clean blood Non-corrosive Usually have detergent compounds spills Limited use as disinfectant properties because of narrow microbicidal spectrum